Ethical physicians, now and then

When I first heard a senior colleague of mine utter these words in the mid-1990s, I was surprised. Time had not been particularly kind to Loeb, who had been the chairman of medicine at Columbia-Presbyterian Medical Center from 1947 to 1960. Among other things, critics had chastised Loeb for being imperious and unwilling to listen; former students had even accused him of bullying them on rounds. This behavior was hardly what I considered to be ethical.

But in researching and then writing a biography of my father, a physician who trained during the Loeb era, I began to understand what my colleague had meant. Bioethics has helped to revolutionize patient care and research since its introduction in the 1970s. But it is instructive to revisit an earlier era in which being an ethical physician did not require input from ethics consultants or ethics committees.

Robert F. Loeb enrolled at Harvard Medical School in 1915 and trained at Massachusetts General Hospital and Johns Hopkins before moving to Columbia in 1921. At Columbia, Loeb did pathbreaking research on Addison’s Disease and co-edited the Cecil-Loeb Textbook of Medicine, but he was best known as a renowned professor. Rounding with a phalanx of students, house officers and visiting dignitaries, he often made diagnoses that others had missed. Loeb’s devotion to his patients was legendary. He rounded seven days a week and knew the names of his current patients, his former patients and their family members.

Although my father, Phillip I. Lerner, entered medical school 40 years after Loeb, his training mirrored the patient-centered model common earlier in the century. Indeed, my dad’s medical school, Western Reserve (later Case Western Reserve), was just introducing a new curriculum that emphasized the humanistic aspects of medicine. My father and his classmates interacted with patients beginning in their first year, even making home visits. As a resident in internal medicine at Boston’s Beth Israel Hospital in the late 1950s, my dad was on call every other night, practically living at the institution. It is not surprising that when he chose a fellowship in infectious diseases, he identified a mentor, Louis Weinstein, whose devotion to patient care and cutting-edge research was 24/7. Weinstein, my father admiringly wrote, was “fanatic, encyclopedic, opinionated, scholarly and demanding of his specialty and all those who aspired to it or intersected its vast boundaries.”

When my father returned to Case Western Reserve as a young professor and infectious diseases consultant in the mid-1960s, he embodied Weinstein’s ethos. I already knew that he stayed in touch with patients and house officers during our family trips. But the journals my dad kept for over 40 years, which I read before writing a book on his career, provided an even clearer window onto his medical practice.

In short, my dad, like Loeb, made a point of getting to know his patients as people — not only where they were from and what they did, but also their values and their beliefs about medicine. When he cared for a woman with a mysterious immunosuppressive illness and multiple infections, he sent slides of her bone marrow to experts across the country and devised experimental regimens to prolong her life. In the case of a woman with leukemia, he encouraged her to let out her anger at him because he believed it helped her compliance. “She screams and carries on when the going gets tough,” he wrote, “knowing that I understand and will never reproach her, never abandon her, whatever!”

This philosophy was thoroughly grounded in the paternalism of the post-World War II era. For example, my father chose not to treat a disseminated lymphoma in an end-stage, suffering HIV-positive man who he had kept alive for three years. He and the patient, my dad wrote, had a “tacit understanding” that my father knew when it was time to let go.

It was this exact type of medical practice, in which doctors “played God” — making life-and-death decisions for patients and at times lying to them — that the bioethics movement sought to reform. Following the civil rights movement, feminism and scandals like Tuskegee, in which doctors purposely withheld penicillin from poor African-American men to study syphilis, it was simply unacceptable to infantilize patients. Patient autonomy and informed consent had triumphed. Being an ethical doctor now meant empowering one’s patients to make decisions.

But if something was gained, something was also lost. Ethical physicians of Robert Loeb’s and my father’s era fanatically learned everything they could about their patients’ diseases and their patients’ lives. Armed with this knowledge, they believed it was their duty to make the best decisions possible for their patients. Anything less — especially offering patients a menu of options — was an abrogation of their responsibility.

There is no going back to the old days. Autonomy is here to stay. Time constraints make it hard to devote the sort of attention to patients that my father did. But it is useful to remember how earlier generations of physicians were themselves ethical — albeit in a very different way.

Ethical physicians, now and then 4 comments

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rbthe4th2

The problem is that doctors nowadays don’t take responsibility for their decisions when wrong or don’t try to become educated or even put forth an attempt to help their patients. Have one who is a multimillionaire made judgements on your care that you can’t afford. Not only are you stuck for then on but then they dump your care because you can’t follow it. Sorry but no matter how much paternalism is stuck up for, until something is done about the issues I put forth, its just not going to work.

Lisa

I do not want a doctor making decisions on my behalf. I’ll take autonomy and informed consent over paternalism, any day, even if that means I have to choose from a ‘menu of options.’

disqus_question_everything

Ethics and informed consent are sorely lacking in the field of gynecology. Despite a 2000 study that 76% of hysterectomies do not meet ACOG criteria, hysterectomy rates are not declining. And marketing tactics by Intuitive Surgical are touting quicker recoveries thereby luring more women into the OR. But hysterectomy has long-term adverse effects that are not being communicated to women by their physicians. And just as astounding is that, in some areas, 73% lose healthy ovaries/gonads (castration) at the time of hysterectomy.

chaplaindl

When you explain why antibiotics are not indicated, you are providing information based on your professional expertise and judgment. That seems to me to be completely consistent with autonomy, and not paternalistic at all. If you would not explain your reasoning or were dismissive in attitude, that would seem paternalistic. There is an important, indeed critical need for physicians, the experts, to provide patients and their families with the full benefit of their expertise. Simply providing a menu of options does not accomplish that..

I have been dismayed (fortunately rarely) to watch discussions with patients and families about end-of-life treatment in which a menu of options is laid out without really testing the hearers’ comprehension of risks and benefits. Then the patient or family as surrogate decision-makers are asked “what would you like to do?” That seems to me to not be respecting autonomy, but to be treating a family and patient unfairly by forcing them to carry the weight of a decision they are not capable of making on their own.

On the other hand, I have seen physicians clearly and carefully outline options, including risks, benefits and best- and worst-case likely outcomes, and then to continue to offer a clear recommendation and reasons for the recommendation. If this kind of discussion is what you meant by using the word paternalism, then by all means be paternalistic. To me this approach is not paternalistic, but respectful to the persons affected by these difficult decisions, and respectful of the role, knowledge and expertise of the physician.

If my physician has a recommendation, I want to hear it. I might weigh factors that I know more about differently from my physician, such as my ability to comply, my tolerance for side effects, my preference for less intervention whenever possible and my finances. It’s my responsibility to provide him or her information about the things that might weigh against my following the recommendation, as that is the only way to find out if there is yet another better way that takes all of that into account as well.

On the other hand, as one other commentator mentioned in an earlier post, if the choice is between a high-handed “take-it-or-leave” it prescription with minimal discussion and explanation, or a menu of options, I would prefer the latter. Respect for me as a person is a prerequisite for a therapeutic partnership between my physician and me. However, not everyone is the same, which requires physicians to be masters of the art of understanding human beings. Fortunately, in my experience, many if not most are.